As we approach World AIDS Day tomorrow, the inspiration of health workers like Dr. Andrew Ocero comes to my mind.

Andrew served as the director of clinical services at the Northern Uganda Malaria AIDS Tuberculosis Programme (NUMAT) until its closing this past summer. NUMAT—a six-year, USAID-funded project in conflict-affected districts of Northern Uganda—was designed to expand access to and utilization of HIV, tuberculosis and malaria prevention, treatment, care, and support activities. In a recent interview, Dr. Ocero told us about the key role frontline health workers had in the success of the program.

World AIDS Day is a time to remember the lives lost to the devastating HIV/AIDS pandemic, rededicate ourselves to working together to creating an AIDS-free generation, and celebrate the inspiring dedication of the millions of frontline health care workers around the world to treat, prevent and care for those affected by AIDS around the world.

Frontline health workers brave often difficult circumstances to ensure those living and affected by HIV in their communities receive the care they need. In Lesotho and Malawi, for example, HIV/AIDS-related deaths are the largest cause of health workforce attrition. Each year, the World Health Organization estimates that up to 170,000 health workers worldwide are exposed to HIV, resulting in 1,000 new infections mostly in low-and middle-income countries.

The tireless efforts of these women and men, many of whom are supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), are paying off. UNAIDS reported last week that 25 countries have seen a greater than 50% drop in new HIV infections since 2001. Half of all reductions in new infections in the last two years have been among newborn children, exemplifying the power of frontline health workers working with pregnant women to ensure mother-to-child transmissions of the virus are prevented.

PEPFAR’s continued success in increasing U.S. support for provision of lifesaving antiretroviral drugs to more than 5.1 million people worldwide is due in no small part to the program’s mandate to support the training and retention of 140,000 health care workers. However, millions more health workers like Andrew are needed if we are to achieve President Barack Obama’s goal of an AIDS-free generation and stronger health systems to address all the health needs of their communities.

The U.S. has the opportunity lead the way to fill the most severe health workforce gaps by enacting an evidence-based, government-wide policy that builds on PEPFAR’s laudable mandate to support frontline health workers. Such a policy can enable Dr. Ocero and millions of our colleagues show us the path to an AIDS-free and healthier generation.

The local people call him “the son of the community.” On the verge of tears, he listens as they proudly say, “The dust will fly even if it’s raining, because we will be dancing.”

The young man is a newly trained agente polivalente elementar, a type of community health worker in Mozambique. At a community meeting in Tete Province, his neighbors are describing how they will celebrate when he receives his health worker kit and begins serving his community.

In Mozambique, the Ministry of Health is counting on these workers to provide basic health services to people in the most remote communities. Due to the country’s severe shortage of physicians, nurses, and midwives, many people don’t have regular access to basic care, and their health has suffered.

Expanding access to health services
In the 1970s, soon after independence, the Ministry implemented a national community health

Community leaders pose for a photo.

program that introduced the agentes polivalentes elementares. The program was interrupted in the 1980s during the armed conflict. Acknowledging international evidence on the vital role community health workers can play in expanding basic health services and meeting health goals, the Ministry and its partners decided to revitalize the program in early 2010.

Community health workers usually act as a point of referral that supports both the community and the formal health system. In Mozambique, they also educate communities on family planning and HIV prevention, counsel pregnant women, identify and manage childhood pneumonia and diarrhea, test for and treat malaria, and provide grassroots support to HIV/AIDS and tuberculosis treatment programs.

A new community health worker rides off to serve her community.

Providing in-country support

The USAID-funded CapacityPlus project, led by IntraHealth International, provided support to roll out the program to the provinces and districts. Key to this was hiring in-country staff to establish operational procedures and policies and coordinate working groups tasked with developing training materials, creating monitoring and supervision tools, and standardizing Medicine and Work Kits that include a bicycle and essential supplies.

CapacityPlus also worked with USAID’s Health Systems 20/20 project to design a performance-based incentives plan for program coordinators who are working to expand the program. In addition, CapacityPlus worked with the Ministry to design and implement a baseline survey to measure program impact.

Building local skills
Scaling up community health worker programs requires strong leadership, political backing, and resources. These workers need to receive adequate management and professional support from the formal health system and be appropriately compensated for their work.

Sandra McGunegill lives in Mozambique and served as CapacityPlus’s senior technical advisor to strengthen coordination of the program. She worked daily with Teresa Mapasse, the national coordinator, increasing her capacity to effectively plan and communicate about the program and supervise provincial coordinators.

As a result, Mapasse now regularly gives presentations to the minister of health and others to engage partners and build political support. She coordinates community health worker training and subsidies, Medicine and Work Kit distribution, program monitoring and evaluation, and the development of Community Health Committees to drive local ownership and involvement.

An insider’s view
McGunegill relays what she heard a community leader say during the meeting in Tete: “Too often, pregnant women infected with malaria were seen riding on the back of a bike, vomiting as they are rushed to the health center.” She glances at her photograph of the new community health worker and adds, “It made it all worthwhile to hear the leader go on to say that now community health workers like this man can test for malaria in the community and distribute medication—and lives will be saved by receiving earlier treatment.”

More than 1,200 agentes polivalentes elementares have been trained to work in 50 districts. There are plans to train another 1,500 in the coming year. This means that many more sons and daughters of Mozambique will be working on the frontlines to offer health services to their communities.

Uganda deserves praise! The government recently committed to recruiting more than 1,014 midwives; 1,436 nurses; 758 nursing officers; 223 medical doctors; 283 anesthetists; 1,101 clinical officers; and 1,360 laboratory technicians for the fiscal year of 2012-13, according to the White Ribbon Alliance of Uganda.

The lifetime risk of death for a pregnant woman in Uganda is 1 in 35, according to the 2011 UDHS report. Additionally, Uganda’s 2012 Human Resources for Health Bi-Annual Report found that the proportion of approved positions filled by health workers at all levels nationally was only 58%, with some district hospitals having as low as only 16% filled posts. The report also found that health workers were poorly motivated and faced unsatisfactory working conditions. The Ugandan government also committed to raising health workers’ salaries from approximately $480 a month to $1,000 month in January 2013, in order to attract more workers to the rural, hard-to-serve areas of the country. This will hopefully relieve the alarming statistic found by a 2008 World Bank study: 80% of public sector medical workers in Uganda work in urban areas, where only 20% of the population lives.

Frontline health workers are often the first point of maternal services for Ugandan women, and they are essential for the management of safe pregnancies. Midwives, nurses and doctors are vital for progress on maternal and child survival. Ensuring that a health worker is within reach, and is trained, equipped and supported, is crucial to the achievement of Millennium Development Goals 4 and 5. During labor, complications cannot always be predicted and may rapidly become life-threatening. Countries where most births are attended by a health professional with the skills to spot and manage complications generally have lower death rates for mothers.

If this commitment from Uganda is fully met, the country’s health sector budget will increase from 7% to about 8% of the national budget. This map and graphic illustrates the critical need for skilled birth attendants across the world, and emphasizes the importance of frontline health workers in saving lives.

Moving forward, the White Ribbon Alliance of Uganda and Coalition to End Maternal Mortality members will convene a reflection meeting to focus on monitoring and accountability mechanisms for these new health funds.

As a frontline health worker here in the U.S., far too often I see babies born prematurely and the long-term and sometimes life-threatening effects of an early birth. It’s difficult to fathom that around the world, 15 million babies are born prematurely every year, with more than 1 million of those babies dying in infancy.

World Prematurity Day is this Saturday, November 17, and gives us all an opportunity to honor the babies born too soon around the world, as well as reflect on the work being done by frontline health workers and researchers investigating what causes pregnancy complications.

The role of frontline health workers is critical to mitigating prematurity, particularly in low-resource settings with limited access to skilled physicians and high-tech hospitals. Often in these circumstances, frontline health workers are the first and only line of defense.

While GAPPS is researching ways to prevent preterm birth, we are also focusing on scaling up known interventions that can have an immediate impact. One model is the Perinatal Interventions Program, which comprises step-by-step guidelines to help health workers in low-resource areas know how to identify and treat women with high-risk pregnancies, as well as care for preterm infants.

However, even if all current interventions were universally applied, the preterm birth rate would drop by less than 20 percent. GAPPS has recently announced five new grants as part of the Preventing Preterm Birth initiative, which is funding innovative research projects to discover the causes of preterm births and develop new ways to prevent them. For example, 125 million pregnant women get malaria every year, and one project is investigating how malaria infections of the placenta affect the immune response which leads to preterm birth and stillbirth.

To help make every birth a healthy birth, it is vital that efforts are well coordinated and that funders understand research priorities. In the new issue of the American Journal of Obstetrics and Gynecology, GAPPS Executive Director Craig Rubens and I authored an article called A framework for strategic investments in research to reduce the global burden of preterm birth, in which we present critical actions that can be taken by both researchers and funders to help advance our shared understanding of adverse pregnancy outcomes.

We hope that this new article will serve as a blueprint for the years ahead. Together, frontline health workers scaling up known interventions, buoyed by innovative research around the world, will lead to preventing prematurity and ensuring safer pregnancies for all mothers and babies.

This is the story of Hope, a cancer patient cared for by the palliative care team of Integrated Hospice Program Cameroon Baptist Convention in Bui Division, Cameroon. Through FHSSA’s Partnership Program, which connects hospice programs in the U.S. with hospice and palliative care programs in Africa to offer financial, educational and clinical support, this program is partnered with Vitas Innovative Hospice Care of Milwaukee. Catherine D’Souza, a frontline health worker shared her experience caring for Hope.

Hope was in a darkened room in the house when I first met her. We knew she was there as we could hear her groaning. Her husband led us carefully through the shadowy house and we stumbled on the uneven mud floor. He removed a single light bulb from the living area and fixed it into the bedroom socket as we went through.

The light flickered and swung as our eyes slowly became accustomed to the gloom and we finally saw what I thought was a pile of blankets. There was Hope. She was sweating and crying as she tried to turn in bed to see us, her face twisted with pain. When she saw our small group standing there she smiled, and lit up the room. ‘Praise God’ she exclaimed.

Hope had been bed bound for one year before we met, and for three years before that she had been seriously ill. She had been to hospital when a small ulcer got bigger and had not gone away. After she was told she had cancer her husband sold all his livestock and possessions for radiotherapy and surgery but she had not improved.

The family had given their goats and chickens as she was promised by one traditional healer after another that they could heal her. Eventually the family couldn’t support her anymore and her husband didn’t have anything left to sell. The local nuns tried their best with soothing poultices as her pain worsened. Although she loved their kind words and prayers, they couldn’t relieve the agony.

Hope was true to her name and didn’t give up her spirit as the months of pain dragged by. I remember the first time I examined her wound. She was really scared, our driver soothed her with calm words and she was amazed that the medicine we had given her had taken the pain away so much that I could examine her without hurting. Hope can now walk around her compound, prepare vegetables, mend clothes and laugh with her neighbours. Her children have their mother back and her husbands’ face does not hold the lines of worry as it did before.

Hope calls her time before she met the palliative care team her ‘dark time.’ We cannot cure Hope’s cancer but we can let her live her life to the full for whatever time she has left.